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The Big Books of Unhappiness

Posted By Randall Reitz and Alicia Hardy, Thursday, June 21, 2012
Updated: Monday, June 25, 2012

Collaborative Care Policy Month

The DSM and CPT manuals are collaborative care's big books of unhappiness.


In his controversial work, Warning: Psychiatry may be Hazardous to Your Mental Health, William Glasser states: "A more accurate title for the DSM-4 would be the ‘Big Red Book of Unhappiness’”. In nowhere is this more evident than in collaborative care.

Each October the American Medical Association releases a new edition of Current Procedural Terminology. Because most insurances bill based on this book, it is highly influential in the maintenance of a fee-for-service system and in setting the fees for the services. A fee-for-service system based on CPT billing will always leave collaborative clinicians unhappy.

Why do we have no love for the DSM and CPT? Because, simply put, these volumes are endemic of why collaborative care has made little progress in the for-profit mainstream of healthcare. And, if left unchecked, a CPT and DSM approach to healthcare will eventually bankrupt the entire system.



CPT codes seem innocent enough. Clinicians use them every day with most every patient. If you’re a medical or nursing provider you bill a 99212, 99213, 99214, or 99215 depending on the complexity of the visit. Behavioral health clinicians have a similar CPT system: 90804s, 90806s, etc. There are a number of inter-related problems with a CPT approach.

First, a fee for service system puts nearly zero onus on the provider of care to ensure that the care was relevant or of quality in nature. The bottom line in a CPT system is extracting profit from patients (and the larger) system, rather than a bottom line of improving health for people and communities. The best indictment of this system was offered by Atul Gawande in his New Yorker article "The Cost Conundrum” (yes, the one with a patient in a hospital gown made up to look like an ATM machine). In this article Gawande compares cities in the US that have the highest cost per patient with those with the lowest costs per patient. In brief, here is how he describes the difference for a hypothetical patient: Gawande's Cost Conundrum

"The damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue. There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?

As Gawande asserts, our CPT-based system is indeed falling apart, both because it is fee-for-service, and because it lacks a collaborative, team-based focus. What does a cost-efficient collaborative system look like? Gawande compares one of the lowest cost healthcare regions in the United States (Grand Junction, CO) with the most expensive (McAllen, TX):

McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.

Gawande provides another example of a collaborative healthcare system in his "Hotspotters” article (yes, the one with a patient bandaged head to toe with a $3.5 million price tag looped around his neck). The creator of the Hotspotter model, Dr Jeff Brenner was the keynote speaker at the 2011 CFHA conference in Philadelphia. This approach uses aggressive care coordination, case management, and patient engagement techniques to induce the $3.5 million patients out of the hospital and into integrated primary care settings. This healthcare system survives entirely outside of the CPT world. Yes, doctors might bill an occasional insurance code to help defray some costs, but very few insurances currently pay for the CPT codes for case management and behavioral disease management that are at the core of promoting health and saving costs.


The Diagnostic and Statistical Manual of Mental Disorders is a reference book for psychiatric conditions and their diagnostic criteria. It grew out of the Statistical Manual for the Use of Institutions for the Insane which listed 22 forms of psychosis, paralysis, melancholia, dementia, neurosis, and the positive psychology predecessor, "Not Insane”. Over time the number of diagnoses has multiplied and the diagnostic criteria have become more precise. For example, since the DSM-3, the manual has not included homosexuality as a psychiatric condition, and the DSM-5 will not include Asperger’s Syndrome. However, early drafts of the DSM-5 have included a number of examples of new diagnoses that pathologize behavior, such as internet addiction, family behavioral patterns, and grief.

Beginning with the DSM-3, the APA has intentionally moved the allegiances and influence of the tome away from Freudian psychoanalysis toward the pharmaceutical industry. In the words of APA’s 2011 President, Carol Bernstein: "It became necessary in the 1970’s to facilitate diagnostic agreement among clinicians, scientists, and regulatory authorities given the need to match patients with newly emerging pharmacologic treatments.” *

The lasting effect of this switch has been to medicalize stressors and symptoms and promote psychopharmaceuticals as the preferred treatment. Marcia Angell provides an excellent overview of the DSM-5 process that is very relevant to collaborative care and inspired much of this information. She describes the short-comings of medically-focused treatments to life ailments as follows:

"Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology. And drug companies have every interest in inducing psychiatrists to do just that.”

The APA allows the pharmacy industry direct influence on the process of identifying new psychiatric disorders and in defining their diagnostic criteria. For example, the head of the DSM-5 task force, David Kupfer self-reports to having served on advisory boards and/or receiving consulting fees from 5 pharmaceutical companies: Eli Lilly, Forest, Solvay/Wyeth, Johnson & Johnson, and Servier and Lundbeck. Under his leadership, DSM-5 task force members are allowed to maintain their positions while continuing to receive up to $10,000 per year from pharmacy companies and to hold up to $50,000 in pharmacy stock. Not all task-force members do report industry ties, but for the DSM-4 every single member of the groups overseeing the important mood and psychosis sections did.** Similarly, in states like Minnesota and Vermont, which require pharmacy companies to report payments to physicians, psychiatry is consistently the top payment receiving specialty.

How does industry influence on the DSM affect collaborative care? As described earlier, it has a direct influence on which services are reimbursed, which directly influences the services that are offered. Angell described the connection as follows:

"At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent. In particular, we need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. Treatment directed at these environmental conditions…should be studied and compared with drug treatment. In the long run, such alternatives would probably be less expensive. Our reliance on psychoactive drugs, seemingly for all of life’s discontents, tends to close off other options. In view of the risks and questionable long-term effectiveness of drugs, we need to do better. Above all, we should remember the time-honored medical dictum: first, do no harm (primum non nocere).”

If a key mission of collaborative care is to increase access to systemic and behavior modification therapies in primary care settings, the DSM system fights directly against this mission. As there is no industry money to support collaborative care, the model is left to fend for itself.

This also affects the research that is published to create the empirical basis for collaborative care. While drug trials are ubiquitous, there are very few strong clinical trials for collaborative care published in top-tier journals. And, those that exist (IMPACT, DIAMOND, etc) place a strong emphasis on  pharmaceutical care management along with integrated behavioral health services.

The DSM also poses a number of operational obstacles for practicing collaborative care: Do behavioral health clinicians in collaborative primary care settings have the luxury of time to complete full diagnostic assessments? Behavioral clinicians often only meet patients for 15-30 minutes. And, as was pointed out in a recent CFHA Blog post, many of us feel overwhelmed by the plethora of brief mental health screens at our fingertips, let alone the prospect of leafing through this behemoth of diagnostic classifications. And yet, at the end of the visit, the empty box for the diagnostic code is there, staring us down, waiting to be entered.

In preparing for this blog post, we spoke with many collaborative care behavioral health clinicians. Many described the DSM as an "imperative” tool; one that assists the clinician in conceptualizing the case, formulating a diagnostic overview, and determining a direction for treatment. Perhaps. Certainly the usefulness of the DSM is clearer in the arenas of specialty mental health, long-term psychotherapy and psychiatry. In primary care? The answer is much less clear.

Our current CPT code system essentially necessitates utilization of the DSM given that a psychiatric diagnosis is required to receive reimbursement for behavioral health care. In 15-30 minute visits, how accurately can a clinician be expected to diagnose a patient, verifying that all DSM criteria are met? One might question how frequently patients are mislabeled with mental health diagnoses that "mostly fit” criteria. We believe that most clinicians try to be as conscientious as possible, and avoid using a diagnostic code when time constraints do not permit a complete evaluation. The result? Thousands (tens of thousands?) of patients circulating through primary care with "anxiety NOS” or "depression NOS”. The NOS label creates a loophole of sorts for primary care. When NOS is listed on a patient’s chart (which is often), rather than reading "not otherwise specified” it more likely means "not enough time, but I want to get paid”.

Requirements of DSM based diagnoses also shift the focus away from prevention, which is a defining element of a population-based, primary care model. A preventative focus would include those patients with unhealthy behaviors, psychosocial stress, poor compliance with their medical treatment. Many of these patients do not meet criteria for a DSM diagnosis. They could be given a v-code, which manages the risk of over-pathologizing and labeling patients, but this does not solve the problem of reimbursement. The way our system is now, it discourages early intervention and preventative care, and rewards (financially) the treatment of those with established mental illness. The underlying message is that if we delay treatment until patients are sick, we can then give them a DSM diagnoses which thereby will help financially sustain our clinics. This simply does not fit with the primary care model.

We do not propose extracting the DSM from primary care completely. It does have its usefulness in providing a framework for complex cases. We do propose, however, that it become viewed as one of many clinical tools that are completely disconnected from reimbursement. Clinicians should not be forced to continually choose between accurately diagnosing a patient according to full DSM criteria, or giving them the information and brief intervention that he or she needs in 15 minutes.

The DSM does have a place in primary care, but right now it is in the wrong place. The right place is on a clinician’s bookshelf, blissfully ignorant of any and all requirements for financial reimbursement. As a clinical tool, it can be useful (at times). But, in the fast-based, prevention focused model of primary care behavioral health, there are definitely many days in which we could do our jobs without ever cracking it open.

In an earlier post on the CFHA Blog, it was observed that the growth of collaborative care has been blunted by our lack of a theme song to rally our sagging hearts. Fortunately, the theme song for the charge against the big books of unhappiness is obvious:

You down with CPT?

Nah, you know me.

You down with CPT?

Nah, you know me.

You down with DSM?

Nah, don’t need ‘em.

You down with DSM?

Nah, don’t need ‘em.

Repeat chorus until healthcare reform renders the song obsolete.



*Carol A. Bernstein, "Meta-Structure in DSM-5 Process," Psychiatric News , March 4, 2011

**Financial Ties Between DSM-IV Panel Members and the Pharmaceutical Industry," Psychotherapy and Psychosomatics , Vol. 75 (2006).

Randall Reitz, PhD is the Director of Social Media for the Collaborative Family Healthcare Association and the Director of Behavioral Sciences for the St Mary's Family Medicine Residency.  He writes CFHA's CollaboBlog.
Alicia Hardy, LCSW is a Licensed Clinical Social Worker and Behavioral Health Consultant at Clinic Ole in Napa, California. She earned her Master’s degree in social welfare from UC Berkeley. Clinic Ole is a federally qualified health center that provides integrated primary behavioral health care to the underserved and uninsured members of the Napa community, which includes a large percentage of monolingual Spanish-speaking patients. Alicia provides direct clinical services as well as managing the clinic’s Behavioral Health Department.

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Shelley L. Meyers says...
Posted Thursday, June 27, 2013
Admittedly, I have not yet worked in a setting in which I was required to have knowledge of CPT coding so I can't speak to that. I am, however, quite familiar with the DSM-IV. Indeed, it is a giant book of unhappiness! You mentioned that we now "medicalize stressors", and I think this is one of the issues that bothers me most. Of course, this also plays a huge role in the reimbursement issue. People are considered "ill" when they have reactions to difficult life stressors. We then add to the stress (my opinion) by calling these reactions a "mental illness". Now that the person has a mental illness we can write their "diagnosis" on a form and get paid. It seems as though providers are caught between the proverbial "rock and a hard place". Label someone with a diagnosis that doesn't quite fit or "sorta" fits (adjustment disorder, anyone?) and submit for reimbursement or nix the diagnosis issue together and the client pays out of pocket. The first option is fraught with huge ethical implications. The second will leave many potential clients without treatment and/or clinicians without potential income. As frustrated as this system is for me, I acknowledge that I have absolutely no idea how to fix it. I do believe that discussions such as this one are a definite step in the right direction.
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Randall Reitz says...
Posted Sunday, June 30, 2013
Shelley, You describe the diagnostic paradox very well. Patients and providers definitely get stuck in picking DSM diagnoses to justify CPT billing. This approach also detracts from a systemic perspective, as it disallows for v-code billing and frames each case as individual pathology rather than systemic mal-adaptation.
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